Leadership Perceptions and Organizational Reality: Barriers to Evidence-Based Emergency Department Misuse Reduction in Community Health Systems

Background Emergency department (ED) misuse remains a persistent problem for healthcare organizations. How leaders perceive the causes and solutions to this issue strongly shapes their strategic responses. This study explores the alignment between senior leadership's perceptions and evidence about ED misuse reduction at a community health system serving a diverse, safety-net population. Methods A cross-sectional exploratory survey of senior managers (N = 47) at a mid-sized community health system in Southern California, was conducted between June 13–27, 2025. This exploratory analysis identified potential areas of perception-data divergence that warrant further investigation in larger samples with sufficient statistical power. Results Three areas of difference emerged between leadership perspectives and operational data. First, leaders identified mental health and substance abuse as primary drivers of ED misuse; however, institutional data show these issues accounted for only 8.3% of all ED visits between 2022 and 2024. Second, while 73.2% of survey respondents reported Human Resources (human factor) influence priority-setting, 55% of leaders cited an insufficient workforce as a barrier to establishing effective priorities. Third, although 55.2% of leaders reported confidence in their ability to discontinue ineffective programs, only one-third reported frequent success with de-implementation. These differences were accompanied by modest ratings in organizational data use capabilities. Conclusions While leadership perceptions diverged from institutional data, these differences may reflect resource intensity considerations not captured in utilization statistics alone. A mid-sized community health system could benefit from enhanced data analytics and formal processes to routinely check leadership perceptions before committing resources to priority initiatives.